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Examining behaviour change techniques (BCTs) in technology-based interventions for enhancing social participation in people with mild cognitive impairment (MCI) or dementia: a scoping review protocol
  1. Di Zhu1,2,
  2. Abdullah Al Mahmud1,
  3. Wei Liu2
  1. 1Centre for Design Innovation, Swinburne University of Technology, Melbourne, Victoria, Australia
  2. 2Beijing Key Laboratory of Applied Experimental Psychology, National Demonstration Centre for Experimental Psychology Education (Beijing Normal University), Faculty of Psychology, Beijing Normal University, Beijing, China
  1. Correspondence to Dr Abdullah Al Mahmud; aalmahmud{at}swin.edu.au

Abstract

Introduction Technology-based interventions have improved the social participation of older adults with mild cognitive impairment (MCI) or dementia. Nevertheless, how these interventions modify social participation remains to be seen, and what efficient behaviour change techniques (BCTs) have been used. As such, this study aims to conduct a scoping review, identifying the features and BCTs behind technology-based interventions that improve social participation for individuals with MCI or dementia.

Methods and analysis The scoping review method will be used to search journal articles from electronic databases, such as PsycINFO, PubMed, MEDLINE, Web of Science, Scopus and reference lists. Following the population, concept and context structure, this study focuses on adults over 60 diagnosed with MCI or dementia. It delves into technology-based interventions, specifically focusing on BCTs, features and overall effectiveness for improving social participation. The research considers contextual factors, exploring the diverse settings where these interventions are used, including homes, healthcare facilities and community centres. This approach aims to provide nuanced insights into the impact of technology-based interventions on social participation in the targeted demographic. Two authors will independently screen titles, abstracts and full texts using Covidence software. Disagreements will be resolved through consensus or a third reviewer, and reasons for exclusion will be documented. We will conduct a detailed analysis of BCTs to pinpoint effective strategies applicable to future technology-based intervention designs. Through this scoping review, we aim to provide valuable insights that guide the direction of future research. Specifically, we seek to inform the development of effective technology-based interventions tailored to support social participation for people with MCI or dementia.

Ethics and dissemination Ethical approval is not necessary, as this review will use available articles from electronic databases. The outcome of the study will be published in a peer-reviewed journal.

Protocol registration number https://osf.io/tkzuf/

  • Health informatics
  • Information technology
  • Public health
  • Dementia
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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Exploration of the impact of technology-based interventions on the social participation behaviour of individuals with mild cognitive impairment or dementia.

  • The current reviews on social participation behaviour change strategies and features will be extended and can be applied when designing technology-based interventions.

  • Guidelines supporting Arksey and O’Malley’s framework will be followed without formally measuring the quality of the studies.

  • Possibly, relevant findings from articles written in other languages must be excluded, as this review will only consider papers written in English.

Introduction

Social participation is a significant issue for older adults and one of the critical components influencing senior citizens’ health.1 It could be considered a healthy behaviour when paired with physical activities, maintaining a suitable diet and refraining from smoking.2 Social participation aids older adults in achieving positive social well-being and satisfying fundamental needs connected to self-actualisation by following specific steps.3 Although people with mild cognitive impairment (MCI) and dementia are challenged by cognitive changes,4 high-level social participation among those with cognitive impairment is critical. Previous research has indicated that enhanced social participation can prevent or slow down mental decline,5–8 maintain significant social roles,9 improve quality of life,10 reduce the impact of cognitive impairment on others11 and minimise social isolation.

Older adults with cognitive impairment may face more significant challenges than those with normal ageing do. Frank et al9 reported that people with MCI may not be able to conduct tasks as they previously had, or they may lose interest. For instance, they are no longer prone to reading or visiting friends (due to the fear of becoming disoriented and unable to understand conversations); hobbies and professional activities should be addressed. Numerous studies have focused on supporting the social participation of individuals with cognitive impairment through non-pharmacological approaches,12 13 such as social intervention14 and mental rehabilitation,15 allowing them to engage in purposeful activities and maintain social relationships.16

Group-based interventions rely on professionals and intervention resources because they require space for activities and facilitators.14 Online support communities positively affect social participation and evoke positive emotions.17 Therefore, an increasing number of technology-based interventions have been developed since they can support or replace facilitators18 and can be found on the internet.19

Inevitably, combining personalised ageing and social participation as multidimensional ideas requires a nuanced approach in the digital world. At the same time, innovative technology solutions must be tailored to meet the idiosyncratic needs of an ageing society and promote their social involvement.20 In a review by Heins et al21 the adoption of social networking technology and information and communications technology training programmes was identified to improve the social participation of community-dwelling older adults. Hence, researchers suggested several technology-based programmes as critical to the intervention, like social robots,22 cognitive stimulating and storytelling programmes23 24 and psychoeducational tools.25 These interventions improved social participation and alleviated cognitive decline. Technology can improve behaviour change techniques (BCTs), as they can be used without a therapist, track performance and adjust difficulty.26 There are three leading approaches by which social participation can be improved via technology: improving cognitive functioning to overcome disabilities,27–29 enhancing social interaction30 and renewing self-competence.31

However, researchers have withheld from describing how technology-based interventions encourage social participation, incorporating specific theoretical models or theories that guide their development and implementation,32 with theoretical mechanisms determining the effectiveness of the intervention.33 In light of the absence of explicit references to theoretical frameworks, a gap exists in our understanding of the underlying principles and mechanisms driving interventions. In review papers on technology-based interventions for individuals with cognitive impairment, the focus has predominantly been on factors influencing the use and effectiveness of the interventions.

For example, studies have explored the barriers and facilitators that arise when using health applications,34 examining the factors affecting the adoption of technology-based interventions.35 BCTs are structured methods incorporated into an intervention to promote behaviour modification.36 BCTs, as defined by Michie et al,36 possess the following attributes: they are a constituent of an intervention aimed at altering a particular behaviour, the smallest element considered to be an active ingredient within the intervention, an observable activity, replicable, specified using an active verb and provide clear details about the targeted behaviour change, fostering agreement among experts. Existing systematic review papers use Michie’s study BCT Taxonomy V.1 to code mobile apps designed for health behaviour changes in areas such as physical activity, diet, drug and alcohol use and mental health.37–39 Exploring BCTs in technology-based interventions deepens our understanding of behaviour change within the context of social participation. This insight contributes to the field’s theoretical foundation, fostering the development of more robust conceptual frameworks. Additionally, understanding effective BCTs guides the design of interventions that are both technologically sound and incorporate evidence-based behaviour change strategies, enhancing overall intervention quality and impact.33 However, existing reviews fail to investigate the BCTs of technology-based interventions for people with MCI and dementia.21 39 40 The review suggests that we ought to explore a more innovative conceptualisation of social participation intervention rather than objective social connection, like the number of people in specific social networks.16 Therefore, a need arises for this research to explicitly incorporate and describe BTCs alongside features guiding the development and implementation of technology-based interventions to promote social participation among people with cognitive impairments.

The integration of BCTs with social participation aims to address the complexity of digital interventions for people with MCI or dementia. Identifying the most effective BCT is crucial for developing engaging interventions that effectively promote positive changes in participants’ health behaviours.37 Recognising that success requires not only technological efficacy but also a nuanced understanding of behaviour change mechanisms, our approach seeks to uncover synergies and challenges in implementing BCTs within interventions targeting social participation. In addition, recent reviews and position papers show that research on technology or technology-based interventions for people with MCI is scarce and heterogeneous,40 frequently missing randomised controlled trials.41 Current technology-based interventions have limited quantitative effects and some qualitative benefits for the social participation of elderly adults with or without dementia.21

Acknowledging potential theoretical disparities, we underscore our commitment to maintaining a transparent methodological approach in this scoping review. Despite the challenges involved, we are dedicated to a critical assessment of the implications arising from the application of a BCTs framework to analyse digital interventions promoting social participation. Drawing from Michie’s comprehensive research, particularly her hierarchical cluster analysis referenced in Michie et al,42 we recognise its widespread consensus and robustness within the field. Aligning our approach with Michie’s work allows us to leverage the established reliability of her research. Furthermore, we emphasise our thoughtful consideration of the underlying ontology, recognising the significance of aligning our methodology with Michie’s theoretical foundations. This careful approach ensures that our study adheres to a well-established framework, enhancing the coherence and rigour of our exploration of BCTs within the context of technology-based interventions for people with MCI or dementia. This scoping review aims to identify future research trends based on international evidence.43 44 Thus, given these preconditions, a scoping review methodology was selected to identify and summarise effective strategies applicable to future technology-based interventions, guiding the development of effective interventions supporting social participation for people with MCI or dementia based on international evidence.

Method

This scoping review will follow the guidelines suggested by Arksey and O’Malley,45 consisting of five stages: (1) formulating the research questions, (2) selecting relevant studies, (3) choosing eligible studies, (4) charting the data and (5) collating, summarising and reporting the correct results. This protocol relied on the preferred reporting items for systematic review and meta-analysis protocol extension guidelines46 and checklist (online supplemental additional 1). Moreover, the scoping review was registered with the Open Science Framework (https://osf.io/tkzuf/).

Stage 1: formulating the research questions

This study aims to conduct a scoping review and identify the features and BCTs of technology-based interventions to improve social participation for people with MCI or dementia. Based on the population, concept and context structure,47 the targeted population encompasses individuals with MCI or dementia. The concept involves a comprehensive investigation into technology-based interventions tailored specifically for this population to improve social participation, including an examination of their BCTs, features, content and usability. Additionally, this research considers various contextual factors, including the diverse settings in which these applications are used, such as homes, healthcare facilities and community centres. The following research questions will be investigated:

  1. How is social participation supported for people with MCI or dementia through technology-based interventions?

  2. What BCTs have been used in interventions to improve social participation?

  3. How effective are technology-based interventions in improving social participation?

Stage 2: identifying relevant studies

The research team chose the relevant search strategy by reviewing pertinent literature and following an iterative approach to refine and finalise it. The search terms were guided by previous systematic reviews.12 In contrast, search phrases were selected to characterise the ideas behind the health condition, the intervention and the study design as part of this review. The following search phrases were used: (‘social participation’ OR ‘social connection’ OR ‘social isolation’ OR ‘social interaction’ OR ‘social activity’ OR ‘social robot’ OR ‘loneliness’ OR ‘social connection’) AND (MCI OR dementia OR Alzheimer OR cognitive impairment) AND (technology OR computer OR tablet OR application OR robot OR internet) AND (intervention OR therapy OR programme OR evaluation). The preliminary search results are found in online supplemental appendix A. The search period was from 2013 to 2023. We will search for papers on PsycINFO, PubMed, MEDLINE, Web of Science and Scopus. These databases were selected because they contain information on health, ageing, social science and digital technologies.

The references discovered on the topic of interest in the papers satisfying the inclusion criteria will be screened by hand. A preliminary search was performed to guarantee that the scope of the review was viable (see online supplemental appendix A for the preliminary research findings). An exemplary search using Scopus yielded 400 results.

Stage 3: choosing eligible studies

Studies must be written in English but can originate from any country. Initially, the search results will be independently screened by two authors at the title, abstract and full-text levels.48 The online screening and extraction programme Covidence will be used48 to conduct all screening stages. Disputes between the reviewers’ decisions will be resolved by reaching a consensus or seeking a third reviewer’s perspective. The reasons for excluding research during the full-text stage will be documented. The final review will entail a flow chart describing the review’s search and selection process.

In this scoping review, we will concentrate on studies involving individuals aged 60 years or older diagnosed with MCI or dementia. The concept of interest will be centred on technological interventions and their effects on social connections and participation outcomes. The expected interventions include technology use training, social networking and storytelling, all of which must exhibit the adopted BCTs. The leading users of the interventions must be individuals with MCI or dementia, not therapists or caregivers. Interventions can be of any length or intensity.

Given this context, our emphasis is exclusively on studies involving community-dwelling older adults. We will also consider studies on older adults living in the community and residential facilities, so long as living arrangements separate the outcomes. To guarantee the inclusion of timely research, this review will exclusively analyse peer-reviewed journal papers published in English over the last decade (2013–2023). In our review, we include studies from the last 10 years, aligning with our goal of conducting a timely analysis of recent research on technology-based interventions for people with MCI or dementia. This deliberate timeframe allows us to capture the latest advancements, interventions and insights, ensuring the relevance of our findings to the current landscape of research and practice and contributing valuable insights to the field.

Published technology-based intervention articles highlighting the effects of social BCTs on the social participation of people with MCI or dementia will be included. In the context of our review, social participation outcomes encompass data related to the impact of technology-based interventions on various aspects of individuals’ engagement in social activities, interpersonal relationships and community involvement. This includes measures of social interactions, communication and the overall quality of social engagement. Studies reporting on improvements or changes in these dimensions will be considered within scope. Conversely, outcomes not directly related to social participation, such as cognitive or physical health measures without a clear connection to social engagement, will fall outside the scope of our review. In addition, studies that fail to mention outcomes related to social participation improvement will be excluded. Social participation-related outcomes may not be the primary results of the investigation. The included articles must mention BCTs and features, with the outcomes measured quantitatively or qualitatively.49 Grey literature, as well as unpublished theses and dissertations, will be excluded to ensure the inclusion of high-quality studies.

Stage 4: charting the data

A data extraction spreadsheet will be designed to extract information from the selected studies.

  1. Publication details: authors’ name, research title, journal title, year of publication and intervention location.

  2. Study design: type of study (randomised controlled trial and case study)

  3. Population: sample size, participant type (MCI or dementia or both) and country.

  4. Concept: the exploration of technology-based interventions focusing on BCTs, features and overall effectiveness.

  5. Context: consideration of diverse settings, including homes, healthcare facilities and community centres.

  6. Intervention details: the template for the intervention description and replication checklist will be used to guide the intervention data extraction.50 The name, aim, procedures and primary features of the intervention will be included to support social participation, BCTs, outcomes of social participation and used technology. Building on Michie’s research. Building on Michie’s research,42 our team will use the classification and descriptions of BCTs provided by Michie, which have 16 clusters with labels, definitions and examples. We will assess the specific design of technology-based interventions in the included articles, identify the types of BCTs employed and subsequently codify them accordingly. This process involves discerning the presence of BCTs in intervention descriptions found in systematic reviews and national outcome datasets, enabling the identification of BCTs associated with effective interventions.

  7. Outcome details: data on the effects of social participation.

Stage 5: collating, summarising and reporting the results

Two authors extract data from the listed research, whereas a third author arbitrates conflicts. Where necessary, the studies’ authors are contacted to gather additional information. Descriptive statistics, like the frequency of the user groups, must be analysed. The analysis offers numerical summaries of the technology-based interventions designed for improving social participation, intervention features, technology types, BCTs and intervention effects. Our goal is to offer a comprehensive overview of existing literature, using the optimal scoping review method and NVivo qualitative analysis software for nuanced exploration of qualitative data.51 Subsequently, the extracted data will be thematically assembled to identify emerging themes. Two reviewers will independently identify these emerging themes and later undergo a joint review by both reviewers to determine the concluding themes.

Patient and public involvement

Patients and the public were not involved in this research.

Discussion

Technology-based interventions can effectively improve social participation for people with MCI or dementia.12 52 In our anticipation of the study’s results, we seek to unveil a nuanced understanding of BCTs employed in technology-based interventions for people with MCI or dementia. Our systematic analysis aims to identify key strategies showcasing efficacy in fostering social engagement and support networks. The significance of our findings lies in their potential contributions to existing knowledge in dementia care, behavioural science and technology-based interventions. Through a thorough exploration of BCTs, our study strives to advance current understanding, offering potential insights into novel approaches for optimising interventions tailored to those with MCI or dementia. These insights hold the promise to inform future research endeavours, guiding the development of more effective interventions. Importantly, they carry practical implications for healthcare professionals, caregivers and policymakers involved in bolstering the social well-being of this vulnerable population. Particularly salient in developing countries, where there is a call for multidimensional initiatives to enhance the social participation of individuals with cognitive impairments.5

Analysing BCTs within the scope of this scoping review paves a clear pathway to enhance the effectiveness of future technology-based interventions for individuals with MCI or dementia. This comprehensive review, identifying and understanding effective strategies, provides evidence-based insights to inform future intervention designs. Such designs can then be more targeted, tailored and impactful, addressing the unique needs of individuals with MCI or dementia. This approach holds the potential to significantly improve outcomes and overall quality of life for this specific population. This review emphasises the shared characteristics of effective interventions to support social isolation, such as providing social activities or group format support.53 The scoping review will offer a comprehensive overview by synthesising a wide range of studies and identifying and summarising the critical features and characteristics of technology-based interventions that can support social participation among individuals with MCI or dementia.

Furthermore, the research discovered that adjusting the task difficulty significantly enhanced the performance of individuals with cognitive impairment.54 The further aim is to identify features to support older adults with cognitive impairment in social participation and summarise how these support social participation through diverse BCTs. It is critical to recognise their importance in primary, secondary and tertiary prevention strategies.55 By explaining the features of BCTs, the review will inform the development and implementation of future interventions, enhancing their effectiveness and relevance when promoting social participation.

Additionally, the review aims to evaluate the diverse BCTs employed within technological interventions and assess their success in improving social participation outcomes since the BCTs, like persuasive technology, may target selective behaviour change more effectively.56 57 Current research reports intervention features like goal setting and feedback as practical BCTs.58 This evaluation will offer valuable insights into the most promising strategies integrated into future interventions to enhance social engagement and interaction. The findings may provide future behavioural markers, facilitating the detection of cognitive impairment.59 Notably, the leading goal of this review is to contribute to the development of a customisable behaviour change model for technological interventions targeting older adults with cognitive impairment, specifically focusing on improving social participation. This model must be practical and feasible for implementation.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors AAM and DZ designed the protocol, and DZ initially drafted the manuscript. AAM offered several rounds of feedback to revise the manuscript and wrote several sections. AAM and WL supervised the project and contributed equally. All the authors approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.